[EMA FOR THE CLINICAL 
STUDY OF MENTALLY AND 
EDUCATIONALLY UNUSUAL 
CHILDREN 



By 
J. E. WALLACE WALLIN, Ph. D. 

Directw-^lect of the Psycho-Educational Clinic in the 
' St, Louis Public Schools 



Being Chapter XIX of The Mental 
Health of the School Child 
pp. 489-450 




New Haven: YAtE University Press 
MDCCCCXIV 



A SCHEMA FOR THE CLINICAL 

STUDY OF MENTALLY AND 

EDUCATIONALLY UNUSUAL 

CHILDREN 



By 
J. E. WALLACE WALLIN, Ph. D. 

Director-elect of the Psycho-Educational Clinic in the 
St. Louis Public Schools 



Being Chapter XIX of The Mental 
Health of the School Child 
pp. 429-450 




New Haven: Yale University Press 
MDCCCCXIV 






Copyright, 1914 

BY 

Yale University Press 




JUL ld'1914 

©CiA376669 



A SCHEMA FOR THE CLINICAL STUDY OF 

MENTALLY AND EDUCATIONALLY 

UNUSUAL CHILDREN 

The scientific study of the educationally exceptional 
child should follow a definite plan of procedure and should 
be sufficiently comprehensive to include an investigation 
of all the important intrinsic and extrinsic factors which 
may mar his development. A complete investigation 
should include the study of the child's developmental, 
family, hereditary and school histories, an investigation of 
his past and present social and physical environment, and 
an examination of his present physical condition and 
anthropometric, educational and psychological status. A 
completely satisfying investigation thus requires the co- 
operation of the social and hereditary worker, the 
teacher, the medical expert and the psycho-educational 
clinician. 

The following schema is offered as a guide to the scien- 
tific examination of mentally abnormal children. It may 
be used in either of two ways. First, the various forms 
may be reprinted on separate blanks with appropriate 
vacant spaces, to be filled in by the investigator. The 
chief objection to this plan is probably financial: blanks 
are expensive, and in few cases will it be possible to fill out 
all the spaces, while in many cases it will not be necessary 
to do so. Second, the investigator may thoroughly 
familiarize himself with the contents of the various forms. 



and follow them as a systematic and comprehensive guide 
to his investigation; but instead of entering the data on 
printed blanks he may write up a 'running history,' giving 
the essential facts of the case, on blank sheets. Whether 
the one plan or the other is followed, it is desirable that 
every investigator should append a brief summary of his 
findings and recommendations. 

It cannot be too forcibly impressed upon social, field 
and laboratory investigators of children that parents and 
relatives — or any from whom bio-social data are sought — 
must be approached with much tact and judgment. 
Gathering hereditary, personal and social data is, at best, 
a very delicate undertaking, subject to many errors, and 
many investigators fail utterly to secure, or otherwise 
they pervert, the significant factors, either because they 
do not know how to approach parents so as to win their 
confidence and put them in a communicative attitude, or 
because they suggest answers by their indiscreet use of 
leading questions. While, therefore, a 'guide' will prove 
of the greatest value to child investigators, they must 
know above all else how to use the guide with tact, common 
sense and discriminating intelligence. 

Social and hereditary investigators must also be 
cautioned against drawing premature or unjustifiable 
conclusions from hearsay evidence. They must accustom 
themselves to weigh reports very carefully, and to verify 
them in every way possible. There is a large amount of 
work done today in heredo-biology, heredo-psychology and 
social investigation which is careless, unscientific and 
worthless. Do not conclude that someone was feeble- 
minded or insane simply because someone reported him 
to be *slow,' *stupid,' 'feebly-gifted' or as acting 'queerly.' 
Do not conclude that a child is feeble-minded simply 



because he appears stupid or feeble-minded to you, or 
because he happens to test three years, or even four or five 
years, retarded. Science cannot be founded on guess- 
work. Gather all possible facts bearing on your case, 
and avoid hasty generalizations. It is rather for the 
trained specialist to supply the diagnoses. 

It need scarcely be said that when the same person 
gathers the developmental, hereditary and school data, it 
is not necessary to re-record on each blank the identical 
facts called for in the different blanks unless there is a 
discrepancy in the statements. 

FORM I 

DEVELOPMENTAL HISTORY 

No. Diagnosis Source of data Date 

Full name Age: date of birth 

yrs. mos. Address (with 'phone) Father's 

name Mother's name Guardian's 

name By whom referred for investigation 

(Underscore appropriate words, and fill in other data) 

CoNCEPTivE CoKDiTiosrs: diseases, syphilis, gonorrhea, tuberculosis, 
scrofula, alcohol, drugs, health, overwork, starvation, fright, accidents, 
anxiety, excitement, aversion, etc., before or at time of conception in 
mother 
in father 

Pregkancy Conditions: above data for mother during pregnancy. 
Also pelvic diseases, attempts at abortion, 'maternal impressions,' 
legitimacy of child 

Birth Cokditions: premature (how much) full term, 

weight labor normal, prolonged (how long) or 

difficult; delivery with instruments or anesthesia; difficult animation, 
breathing or crying, cyanosis; injury or deformity (especially of 
head) or paralysis; inability to suckle 

Growth Conditioxs: nursed (by whom, how long) 
Bottle fed (how long, what) What fed when 

weaned Sickly as baby or child First 



teeth, when (any fever or illness) Second teeth, 

when Fontanel, closed when First 

crawled, when Stood alone, when 

Walked (unsupported steps), when Walked well, 

when Ran well, when Supported head, 

when Talked — single words correctly applied, 

when Short phrases, when Complete 

sentences, when Specific speech defects, what, 

since when, circumstances Able to hold or grasp well, 

when Control of fundamental reflexes (acquisition 

of tidy habits), when Beginning of puberty 

Of menstruation (diflBcult) 

Diseases akd Accidents (age, attributed cause, severity, subsequent 
eflFects, recovery) : measles, smallpox, whooping cough, scarlatina, 
scarlet fever, mumps, diphtheria, cerebro-spinal meningitis, infantile 
paralysis, rickets, malnutrition, inanition, scrofula, swollen glands, 
adenoids, enlarged tonsils, nose, eyes, ears, nervousness, muscular 
twitches, where chorea, periodical headaches, fainting 

spells, convulsions (infantile or epileptic, with data) 
enuresis (nocturnal or diurnal), falls, injuries, orthopedic deformities, 
pubertal or menstrual troubles Vaccinated, when, 

effects Hospital or surgical record 

M. D.'s by whom examined or treated 
Diagnoses by different M. D.'s 

Habits: sleep (past and present) : hours of retiring and arising 
sound, restless, insomnia (cause). Drinking: 
tea, coffee, wine, beer, whisky; drugs (how much, how frequently) 
Appetite: hearty, poor, capricious, gluttonous, food 
preferences, usual menu Chews or smokes: cigarettes, 

cigars, pipe. Excessive indulgence in sweets Masturbates, 

sexually immoral or perverse. 

Mental and Physical Peculiarities in Infancy and Childhood 
(age first observed, parents' explanation) : queer or bizarre ideas, 
action, behavior, speech, disposition Fits of crying or 

laughing, with or without cause Outbreaks, tantrums, 

continuous or periodic Night terrors, sleep-walking 

Morbid fears Criminal, intemperate, immoral or 

destructive tendencies Running away Solitude 

or company preferred Shut-in, solitary disposition 

Playing or seeking younger or older persons or opposite sex 
Dull, stupid, lazy, indifferent, bright, talented, precocious (with 
facts) 



Record of Delinquekcies (with ascribed causes, institutional, 
court and probation records) : 

Agencies which have previously been interested in this child: 

Additional Remarks: 

Recommendations (by whom) : 

Results of Following Recommendations (as reported later) : 

Signature : 

FORM II 

FAMILY AND HEREDITARY HISTORY 

No. Diagnosis Source of data Date 

Full name Bom, where Age: date of 

birth yrs. mos. Lives with at 

(street, with 'phone) Name, with birthplace, nationality 

and religion of father of mother 

Language spoken at home Order of child's 

birth no. of sisters, alive dead of brothers, 

alive dead Age of father at child's birth of mother 

Blood relationship between parents Parents living 

apart, together, divorced. Occupation and weekly earnings of father 

of mother of other children of child 

Health, morals, habits, diseases, sexual habits, etc., prior to birth of 
child, of father of mother (see Form I) 



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FORM III 

HOME AND NEIGHBORHOOD ENVIRONMENT 

No. Diagnosis Source of data Date 

Full name Age: date of birth 

yrs. mos. Address (with 'phone) Lives 

with Parents' address, if different 

Father's name Mother's name 

Parents alive Parents living together If 

separated, divorced or deserted. Guardian's name and address 

Child's birthplace Language spoken in 

home Referred for investigation by 

Successive places of residence (with sanitary, hygienic and moral 
conditions of each) 

Present Home Influences 
(Underscore appropriate words, and fill in other relevant data) 

Financial: rich, moderate, poor, impoverished, proverty-stricken, 
charity case. Weekly earnings of father mother 

children Breadwinners, who Influence of financial 

conditions on child's care 

Food: quantity quality Drinks: 

what how often how much No. of meals 

(typical menus) 

Clothing: ample, insufficient, shabby, soiled, tasteless, immodest 
(effect on child) 

Bathing: frequency 

Housing: flat, tenement, house; no. of rooms of bedrooms 

bathroom no. of lodgers in family of boarders 

Clean, bright, sunshiny, artistic, attractive, dark, dingy, damp, filthy, 
disordered, well or poorly ventilated. Garbage Sewerage 

Child's bedroom: quiet, good ventilation, light, sleeping companions, 
no. in room Hours of retiring and arising 

Home Life: excellent, tranquil, religious, moral, refined, upset, dis- 
turbed, boisterous, raw, quarrelsome, brutal, fighting, vulgar, degrad- 
ing irreligious, immoral, bad. 

Home Treatment: excellent, good, kindly, good care, indifferent, 
neglectful, poor care, parents away, petted, coddled, well or poorly 
disciplined, ridiculed, rebuffed, irritated, maltreated, whipped, 
frightened, abused, by father, mother, stepmother, siblings, guardians, 
etc. Overworked 



Child's Deportment at Home: excellent, good, average, poor, bad; 
obedient, disobedient; mischievous, quarrelsome, fights, cruel to 
animals or siblings or playmates, incorrigible, destructive; cheats, 
steals, squanders money, pawns, gambles, plays craps, deceives, lies, 
untrustworthy; neat, careless, indolent, immodest, immoral; runs 
away. Attitude toward parents, siblings, playmates, strangers 
Toward reprimands and punishment How punished 

Deportment of siblings at home 

Amusements at Home: what, cards, games, plays, singing, music, 
reading, proper, improper. How does child spend leisure time? 

Chief interests at home Vacations, 

when where spent 

Work: complete record of jobs, with dates, how long held, hours, 
pay, success, reasons for changes or discharge 
Age on taking first job 

Religious Disposition: religious, irreligious or indifferent. Attends 
church, where, how often, willingly or reluctantly 
Attends Sunday school, where, how often, willingly 

Neighborhood Influences 

Physical Surroundings: sanitary, insanitary, dark, smoky, filthy, 
slummy, densely populated, foreign population, saloons, dance halls, 
gambling joints, picture shows, immoral resorts. 

Social Environment: character of chums or associates (boys, girls, 
adults), good, bad, vulgar, gamblers, crap players, immoral, corrupt, 
criminal, thieves. Belongs to clubs or gangs, as leader or follower, what 
kind (social, amusement, literary, predatory, criminal, etc.), effects 
of on child Tendencies toward loafing, vagrancy, migration. 

Recreation facilities of neighborhood: playgrounds, public, private, 
supervised, unsupervised, streets, home yard, athletic field, gymnasium, 
social settlement house. Seeks what kinds of amusements (games, 
plays, loafing, running around, ball, gambling, crap playing, immoral 
practices, selling papers, theaters, picture shows, etc.). Plays with 
boys or girls, older or younger. Attends picture shows or theaters, 
how often What kind of shows preferred 

Effects of on child 

Recommendations : 

Results op Recommendations (from later investigations) : 

Signature : 

10 



FORM IV 

SCHOOL HISTORY 

Teachers' Reports ok Pedagogical, Psychological, Social akd 

Moral Traits 

No. Diagnosis Reported by (with position) 

Date Full name Sex 

Age: yrs. mos. Birthday Address (with 

'phone) Parents' or guardian's name (and address, 

if diflPerent from child's) Nationality, language 

and religion of father mother 

Language spoken in child's home By whom referred 

(Underscore appropriate words : once for 'moderate,' twice for 'marked,' and 
thrice for 'extreme' degree. Also fill in data in blank spaces.) 

Attendance Record: Age on entering first school (kindergarten 
included) 



Names of schools 

attended, in 
correct time order 



Location of 
School 



Time, 
from to 



No. of 

months in 
attendance 



Grades 
completed 



Grades 
repeated 



(1) 
(2) 
(3) 
(4) 



Repetition: number of months spent in each grade child has repeated 

Total time (years or months) spent 
repeating work Retardation: grade in which child 

should be according to age Present grade 

Amount of pedagogical retardation (yrs. and mos.) 
Attendance, regular or irregular, during past or present time 
(ascribed causes of irregularity) 

Past Record: character of work, conduct, disposition, traits, etc., 
as reported from previous teachers or specialists 

Present Pedagogical Status: School ej^ciency in general: excellent, 
good, fair, poor, very poor, total failure. Prospects of promotion: 
excellent, good, fair, poor, none. Poorest work in which branches 
Best work in which branches 



11 



Special aptitudes, what Greatest interests, or likes, in 

school work Greatest dislikes 

Pedagogical traits in which strongest In which 

most deficient Learning capacity: is child good 

or poor in ability to observe to concentrate 

to memorize (mechanically, logically, understandingly) 
to retain to express orally or in writing to 

form habits to adapt self to new or changing situations, 

conditions or emergencies to think, judge, reason, imder- 

stand to do independent work to lead 

to direct to originate, invent to keep a level 

head (easily confused) Learns best by repetition, rote, 

memorizing, reasoning, imitation, reading, being told, doing or 
experimenting for self (hit or miss). Accomplishments: in reading: 
knows alphabet (letters not known) reads in what 

reader how well reads at sight, syllables, short 

words, long words, spells out words In arithmetic: 

counts, how far Ability in addition, subtrac- 

tion multiplication division 

problems How far advanced Best in 

concrete or abstract work In spelling: sample words 

child can speU Words child cannot spell In 

writing In drawing In grammar In 

language work In speaking, dramatizing 

In music In kindergarten In manual train- 

ing In shop work In domestic science 

In school gardening In gymnastics, games In 

history In geography Ability of brothers 

of sisters 
Reported defects or capacities of mother 
of father 

Attitude Toward School Work: interested, willing, tries, indus- 
trious, energetic, cheerful, trustworthy, lazy, slovenly, careless, shirk- 
ing, despairing, difl&dent, non-persevering, easily wearied or fatigued, 
grows sleepy, dopey, disinterested, bored, inattentive, complaining. 

Attitude Toward Correction, Reproof or Pun^ishmestt: heedless, 
resentful, headstrong, obstinate, talks back, abusive, sensitive, cries, 
indiflPerent. Very responsive, tries to improve, takes it with good 
grace. 

Attitude Toward Plays and Games: seeks or avoids games. Plays 
much or little. On playground Plays with boys or 

girls with younger or older children 

12 



Fond of what games or plays Plays make-believe 

plays ability to plan or lead games 

Gets confused in games Loses self-control 

Behavior in games 

Mental, Moral and Social Traits: Circumspect, deliberate, 
thoughtful, thoughtless, impulsive, careless, slothful, slovenly, lazy, 
inert, slow, dull, stupid, apathetic, unresponsive, taciturn, reticent, 
diflfident, retiring, bashful, quiet 

Bright, talented, precocious, quick, responsive, talkative, loquacious, 
communicative, entertaining, boring 

Cheerful, good-natured, gay, humorous, kind, affectionate, sympa- 
thetic, helpful, generous, frank, obedient 

Moody, sensitive, despairing, fretful, cranky, resentful, malignant, 
defiant, angry, meddlesome, complaining, quarrelsome, trouble maker, 
brutal, fights, kicks, scolds, nags, spiteful, jealous, sullen, selfish, 
self-centered, proud, domineering, bossy, changeable moods, capricious 
disposition or character 

Graceful, artistic, neat, awkward, clumsy, poor gait, poor motor 
control, stumbles, falls, injures self 

Bold, reckless, heedless of danger, venturesome, blustering, noisy, 
fearsome, cowardly 

Restless, fidgety, nervous, scowls, twitching movements (of what) 

excessive movements, emotional, excitable, 
impulsive, passionate, violent 
Strange or peculiar actions, habits, speech (what) 
Sudden or capricious outbreaks of passion, anger, fear, destructive 
tendencies, love, gaiety, laughing, crying, tantrums, fits, fainting 
spells. Automatic actions (when excited or otherwise) 
Suspicious, solitary, seclusive, shut-in, avoids company, dreamy, 
observant 

Honest, truthful, pure, modest; dishonest, untruthful, steals, lies, 
profane, swears, obscene, lewd, masturbates, immoral 
Any sense of shame, of difference between right and wrong, of guilt, 
remorse, sorrow, reverence, religion 

Speech: stutters, stammers, lisps, lalls, indistinct, inarticulate, 
sluggish, mumbling, thick, incoherent, halting, jerky, rambling, point- 
less, labored; clear, fluent, logical, sensible, braggadocious, egotistical, 
gossipy; declaims, recites, sings 

Headaches, eyestrain, holds eyes near work, mouth open, poor hearing, 
takes cold easily, running nose, gets sick, tired 
Smokes, chews. Data from school medical record: 

13 



What special measures have been taken to overcome the child's 
pedagogical deficiencies ? 
To overcome his physical defects 
His moral or social shortcomings 

Results of These Measures: 

Recommendations : 

Results of Following Recommendations (from later inquiries): 

Signature : 

FORM V 
PHYSICAL AND ANTHROPOMETRIC EXAMINATION 

No. Diagnosis Examiner Date 

Full name Sex Birthday 

Age: yrs. mos. Address Parents' or 

guardian's name (and address, if different, with 'phone) 

Brought by Referred by 

(Underscore appropriate words: once for 'moderate,' twice for 'marked,' and 
thrice for 'extreme' degree. Supply all relevant data in blank spaces.) 

Defects, Diseases, Disorders and Stigmata 
(Anatomical, physiological, neurological) 

General Appearance: Expression nutrition 

Fat, corpulent, lean, emaciated, fair, normal. 

Skin: complexion; pallid, sallow, ashen, oily, moist, dry, leathery, 
wrinkled, baggy, florid, scars, birthmarks. 

Teeth: carious (number, degree) roots, tartar, 

impacted, irregular, malocclusion, rachitic, serrated, pointed, Hutch- 
inson's Gums 

Tongue: thick, pointed, large, small, furrowed, enlarged papillae. 

Throat: tonsils, enlarged, atrophied, submerged, pitted, soft, 
removed. Pharyngitis. Laryngitis. Mouth breather. Lymph glands. 
Thyroid, enlarged, atrophied. Adenoids. 

Palate: cleft, V-shaped, arched, narrow. 

Lips: normal, hare-lip, thick, thin, everted, fissured. 

Nose: deflected septum, enlarged turbinates, polipi, rhinitis, broad 
base, sunken bones, squat, mongoloid, cretinoid. 

Eyes: acuity, R L Astigmatism Small 

palpebral fissure, exophthalmos, choked disc, scotoma, hemiopsia, 
irregular or eccentric pupils, ptosis, oblique mongolian, epicanthus. 

14 



Nystagmus, strabismus, diplopia, accommodation to light to 

distance Argyll-Robertson 

Iris, color, R L Wearing proper or improper glasses 

Ears: acuity, R L Rinne Otitis media, 

R L Impacted cerumen, perforated drum, otorrhea. 

Large, small, Darwinian tubercle, lobule absent, fossae absent or irre- 
gular, pinna (size, shape) asymmetries 

Face: immobile, mobile; forehead, Bombe, receding, low or narrow; 
prognathous jaws, asymmetries 

Head: hydrocephalic, macrocephalic, microcephalic, rachitic, syphi- 
litic, cretinoid, asymmetries. Hair: color coarse, dry, oily, 
scant, brittle. Pediculosis. 

Shoulders: round, square, stooped, asymmetrical. Scaphoid scapula 

Spi3s^e: scoliosis C D L lordosis, C D L 

kyphosis 

Chest: flat, rachitic, pigeon, funnel, barrel-shaped, asymmetrical. 
Lungs Respiration, rate character 

Upper Limbs: 

Lower Limbs: 
Flat foot 

Circulation: good, poor. Heart: dilation, murmurs, displacements. 
Pulse: volume rate rhythm pressure Veins 

Arteries Blood examination: red corpuscles 

white corpuscles hemoglobin color index 

Widal Wasserman 

Alimentation: appetite digestion abdomen 

stomach intestines 

Genito-Urikary System: 

Neuro-Muscular: tone, relaxed, flabby, tense. Corrugation, over- 
action of frontals. Tremors, coarse, fine, unilateral, spastic, jerky, 
intermittent, rhythmical, of what parts Hand balance: 

relaxed, tense, drooping, asymmetrical, finger twitches Station: 

relaxed, unsteady. Head balance Gait: normal, lively, 

clumsy, shuffling, spastic, ataxic, waddling. Paralyses 
Contractures Fainting spells Tics 

Habit spasm Convulsions Chorea 

Epilepsy Hysteria Headache, migraine 

Anesthesias 

Reflexes: patellar, R L Clonus Babinski 

Other reflexes Defective speech 

Other Defects or Stigmata: 

15 



Active Disease Processes: record the diseases, and indicate whether 
slight or serious, of the integumentary, skeletal, muscular, nervous, 
nutritive, respiratory, circulatory, lymphatic, excretory and repro- 
ductive systems. 

History of Diseases, Deformities axd Accidents, with Previous 
Medical Diagjstoses: 

Name of Examiner: 

Physician's Recommendations: 

Results of Recommendations (as later ascertained): 
Physician or hospital recommended: 

Anthropometric Measurements 

Weight: lbs. kg. Stature, net standing (mm.) 

Sitting Ponderal index Statural index 

Statural type Spread of arms 

Spirometry: 12 3 Chest girth (below level of axillae): 

maximal inhalation exhalation normal Vital index 

Dynamometry: Rl 2 3 LI 2 3 Head 

measurements: circumference height length (antero- 

posterior diameter) breadth cephalic index 

Other measurements 

FORM VI 

PSYCHOLOGICAL EXAMINATION 

It has been deemed wise to omit a schema for conducting psycho- 
logical examinations for the following reasons. First, a considerable 
number of graded scales for testing intelligence (particularly versions 
of the Binet-Simon scale) are now easily accessible in English. 
Second, hundreds of different psychological tests and experiments are 
equally accessible in the standard books dealing with psychological 
tests (e.g., the manuals by Whipple, Franz, Titchener, Sanford, 
Starch, Scripture). It would be futile to attempt to print a selected 
list of such tests here, because the expert experimental psychologist 
is qualified to make his own selection, while the inexperienced 
psychologist (physician, nurse, teacher) would scarcely be able either 
properly to conduct the experiments without technical training, or 
elaborate explanations, or correctly to interpret the findings. Third, 
there is little profit in outlining a comprehensive series of tests until 
reliable clinical norms are available. Unfortunately such norms are 
not yet available. The fact that this is so makes it all the more 

16 



necessary that the clinical psycho-educational examiner should possess 
very extensive first-hand experience with many types of mentally 
unusual children, so that he will be able to diagnose cases fairly 
accurately with the aid of a minimal number of tests. 

FORM VII 

PEDAGOGICAL EXAMINATION 

Until we have available a series of clinical pedagogical age-norms, 
in various school studies, established by objective tests given under 
standard and controlled conditions, possibly to individuals rather 
than to groups — such as the Courtis scores in the fundamental mathe- 
matical processes, though these are group norms — it would be of 
little avail to outline a schema for the pedagogical testing of the child. 
We have, to be sure, the pedagogical scales by Vaney and Holmes, 
but the former is very limited in range and not entirely appropriate 
to pupils trained by American school methods, while the latter has 
not been experimentally derived by objectively testing individual 
children of various ages (the method of derivation is not revealed). 
It is merely an abbreviated course of study for grades two to five 
which, it is assumed, represents the pedagogical accomplishments of 
normal children. Until we possess satisfactory pedagogical age scales 
of development, it will be necessary to use (but with discriminating 
judgment) the school record of the child (Form IV). 

FORM VIII 

SUMMARY OF IMPORTANT FINDINGS 

It is very desirable that social or field workers epitomize for the 
busy examiner the chief findings. This blank should be comprehen- 
sive, yet very brief: it should contain only the data which seem to 
have an important bearing on the case, which are important for 
diagnosis and prognosis. It may also include the chief results of the 
physical, anthropometric and psychological examinations, the final 
(or at least the provisional) diagnosis, the recommendations, a record 
of treatment, the results of treatment, and the final disposition of the 
case. 

The question naturally arises whether it is necessary or 
indeed desirable to make such an exhaustive investigation 
of each case as that contemplated by the above schema. 

17 



The answer is that it is usually desirable, but not always 
necessary or possible to do so. Unless the clinicist has at 
his command the necessary staff of assistants he must 
content himself with a far less thorough investigation. He 
should, however, at all times attempt to secure a certain 
Trdnimum of data which bear significantly upon psycho- 
educational cases. Such a minimum is represented, I 
believe, by the following abbreviated record blank. It is 
reproduced from the routine blanks which have been in 
constant use in my clinic for several years. 

FORM IX 

ABRIDGED RECORD BLANK 

Child's name (with street and city address and 'phone) 
Parents' names (with address and 'phone, if diflPerent) 
Referred by Brought by Date 

Data secured from Recorded by 

Exact age: date of birth Age in yrs. and mos. 

Place of birth Nationality of father of mother 

Language spoken at home 

I. Pedagogical Record 

School now in All schools attended, in correct time 

order, with dates 

Age on entering first school (including kindergarten) 

Number of years (or months) in school Present grade 

In what grade should child be according to age Years 

retarded Number of years (or months) in each grade 

(including kindergarten) 

Grades repeated (indicate whether one, two or three years) 

Will child be promoted this year Attendance 

Greatest capacities, abilities or talents shown in school work (best 

subjects) Greatest interests 

Greatest deficiencies, worst faults, poorest school subjects 

Physical, mental and moral characteristics, disposition, deportment 

Other comments by teachers 
School medical inspection record 
School record of brothers and sisters 

18 



II. Home and Ekvironmental Conditions 

Parents alive Living together Breadwinner 

(who) Financial conditions Home sanitary, 

well ventilated, clean In house, tenement, shack, apart- 

ment In good or bad (slummy or immoral) neighbor- 

hood Social or moral conditions in home 

Home treatment (child neglected, cruelly or kindly treated, well 
cared for) What does child usually eat 

What does child drink Hours of retiring and 

arising Does child keep bad company 



III. Child's Developmental Histort 

Birth conditions: on time premature (how much) 

Labor, how long With instruments Birth 

injuries How nursed (length) 

Health as babe Infant and child diseases (state age, 

severity, after effects) : Croup Whooping cough 

Chicken-pox Measles Diphtheria Scarlet 

fever Typhoid Pneumonia C.-s. menin- 

gitis Infant paralysis Spasms (describe) 

Enuresis Accidents By whom previously examined 

and diagnoses given 

First teeth, when (any illness) Fontanel closed 

First stood alone First sat up First steps unsup- 

ported First walked unsupported First used single 

words Short phrases or sentences 

Mental and physical peculiarities in infancy and childhood (age 
first observed): queer or unusual behavior, talk or ideas; emotional 
fits or outbreaks, fears, night terrors, destructive, disobedient, 
vagrancy, truancy, veracity, delinquencies, bad sex habits, social 
traits, play tendencies, stupid, sluggish, quick, bright 



IV. Hereditary Factors 

Health, habits, diseases, drink, etc., of father and mother before and 
during conception 

Pregnancy conditions (overwork, poor health, infection, drink, 
abuse, starvation, etc.) 

Age of mother at child's birth of father Parents 

related 

19 





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Order of child's birth 



Number of Sisters 
Number of Brothers 



Give facts in regard to the following defects, conditions or diseases 
found in the child's brothers, sisters, mother, father, maternal and 
paternal great-grandparents, grandparents, aunts, uncles, first and 
second cousins, etc.: 



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